Narrow portion of the terminal choledochus is a cause of upstream biliary dilatation in patients with anomalous union of the pancreatic and biliary ducts

AIM: To clarify the pathogenesis of biliary dilatation associated with anomalous union of the pancreatic and biliary ducts (AUPBD). METHODS: Direct cholangiopancreatograms of 350 adult patients with or with suspicion of hepatobiliary or pancreatic disorders were reviewed. AUPBD was diagnosed cholangiopancreatographically, when the pancreaticobiliary ductal union was located above the narrow distal segment of the bile duct, which represents the action of the sphincter of Oddi. The narrow portion of the terminal choledochus was defined as symmetrical stricture of the common bile duct just above the pancreaticobiliary ductal union. RESULTS: AUPBD was found in 36 patients. Among ch-olangiopancreatographic features, the narrow portion of the terminal choledochus was the most pathognomonic for AUPBD (accuracy, 98%); it was present in 29 (81%) patients with AUPBD, but was not found in any patients without AUPBD. Among patients with AUPBD, biliary dilatation (>10 mm) was more frequent in those with the narrow portion of the terminal choledochus (23/29) than in those without (2/7; P = 0.018) AUPBD. Among the patients with both AUPBD and the narrow portion of the terminal choledochus, there was a strong negative correlation between the minimum diameter of the narrow portion and the maximum diameter of the choledochus (r = -0.78, P<0.001), suggesting that the degree of biliary narrowing at the narrow portion correlates with that of upstream biliary dilatation. CONCLUSION: The narrow portion of the terminal choledochus, a pathognomonic radiologic feature of AUPBD, may be a cause of biliary dilatation in patients with AUPBD.     

胆源性胰腺炎和胰胆管合流异常的关系

目的 探讨胆源性胰腺炎(ABP)和胰胆管合流异常(anomalous pancreaticobiliary ductalunion,APBDU)的关系.方法 选择ABP患者131例,入院后抽取静脉血检查总胆红素(TB)、ALT、AST、ALP,γ-GT.先行非手术治疗,待病情稳定后复查上述指标,然后择期手术,并行术中胆道造影,观察胰胆管合流情况.结果 131例ABP患者中发现APBDU 27例,占20.6%.其中胆总管汇入胰管(Ⅰ型)8例,占29.6%,胰管汇入胆总管(Ⅱ型)16例,占59.3%,复杂型(Ⅲ型)3例,占11.1%.经非手术治疗后,TB、ALT、AST、ALP、γ-GT含量均较入院时明显降低(P＜0.05),其中APBDU患者的ALT为(71.81±23.19)U/L,AST为(47.85±27.87)U/L,γ-GT为(52.86±31.49)U/L,仍明显高于无APBDU患者的(51.96±15.40)U/L、(40.77±16.58)U/L和(34.86±26.47)U/L(P＜0.05).结论 胰胆管合流异常足导致ABP的重要原因之一.     

Endoscopic retrograde brush cytology (ERBC) of the biliary and pancreatic ducts.

A new device with a brushing tube that can be introduced through the biopsy channel of the duodenoscope (Olympus JF B) used for cannulation of the papilla of Vater is reported. In 17 patients in whom ERCP had demonstrated ductal abnormalities, an endoscopic retrograde brush cytology (ERBC) was performed. A cytological diagnosis of malignancy was made in 8 patients and a possible malignancy in 2 cases. Seven cases were operated upon, and a malignant tumor was found in 6. In one case a malignant tumor was found at autopsy. Histological examination was performed in 6 cases and showed adenocarcinoma in all.. Two patients with malignant cells and ERCP-findings of suspected pancreatic carcinoma were not operated upon. The tumours were localized in 1 case to the papilla of Vater, in 2 to the biliary duct, in 4 to the pancreatic head, and in 2 cases to the pancreatic corpus. No complications occured. It is concluded that this technique provides information supplementary to that of other diagnostic procedures.     

Fusion variations of pancreatic ducts in patients with anomalous arrangement of pancreaticobiliary ductal system

Fusion variations of the pancreatic ducts were studied to elucidate the significance of such variations. We classified structural fusion anomalies of the main and accessory pancreatic ducts on endoscopic retrograde cholangio-pancreatography (ERCP) in 37 patients with anomalous arrangement of the pancreaticobiliary ductal system (AAPB). The fusion variations of the pancreatic ducts were classified into five types: common, ansa pancreatica, branch fusion, looped, and separated. These fusion variations, except for common type, were found in 68% of the 37 patients with AAPB on ERCP. Fusion variations of the pancreatic ducts were very frequent (93%) in the 30 patients with congenital cystic dilatation of the common bile duct (CCD). The branch confluence fashion, in which the terminal bile duct communicated with a pancreatic duct branch, was found only in patients with cystic dilatation cyst of the CCD, and it appeared that cystic dilatation cyst of CCD might differ from spindle or cylindrical cyst originating from embryonic formation of an anomalous confluence. It was also suggested that in patients with fusion variations of the pancreatic ducts, the flow of pancreatic juice might be disordered, leading to the development of acute pancreatitis or pancreatic dysfunction. Consequently, it appears to be necessary to carefully examine patients with AAPB for the presence or absence of any fusion variations of the pancreatic ducts and to observe such patients with long-term monitoring by ERCP, and computed temography, and with pancreatic function tests.     

EUS-guided rendezvous drainage of obstructed biliary and pancreatic ducts: Report of 6 cases

BACKGROUND: Only a few cases have been reported of EUS-guided drainage of obstructed pancreatic or bile ducts. An initial experience with EUS-guided rendezvous drainage after unsuccessful ERCP is reported. METHODS: EUS-guided transgastric or transduodenal needle puncture and guidewire placement through obstructed pancreatic (n=4) or bile (n=2) ducts was attempted in 6 patients. Efforts were made to advance the guidewire antegrade across the papilla or surgical anastomosis. If guidewire passage was successful, rendezvous ERCP with stent placement was performed immediately afterward. RESULTS: EUS-guided duct access and intraductal guidewire placement was accomplished in 5 of 6 cases, with successful traversal of the obstruction, and rendezvous ERCP, with stent placement in 3 of 6 cases (two biliary, one pancreatic). The procedure was clinically effective in all successful cases (two patients with malignant obstructive jaundice, one with relapsing pancreatitis after pancreaticoduodenectomy). There was one minor complication (transient fever) but no pancreatitis or duct leak after successful or unsuccessful procedures. CONCLUSIONS: EUS is a feasible technique for allowing rendezvous drainage of obstructed biliary or pancreatic ducts through native papillae or anastomoses after initially unsuccessful ERCP.     

Analysis of pancreatic enzymes in the bile of congenital choledochal cyst with anomalous pancreaticobiliary ductal union

Pancreatic enzymes in the bile of congenital choledochal cyst with anomalous pancreaticobiliary ductal union were analyzed. Almost all pancreatic proteases were already activated in the bile aspirated immediately after insertion of PTCD tube. However, inactive proteases gradually increased after continuation of drainage by PTCD. Pancreatic protease activities appeared again after clamping the PTCD tube. In vitro study of trypsin activities in the bile containing no initial trypsin activity, active type of trypsin did not appear throughout the experimental period. It is suggested that continuous reflux of pancreatic juice into the bile and certain incubation time are necessary for activation of pancreatic protease in bile of congenital choledochal cyst.     

Radiographic assessment of anomalous bile ducts

We report 5 radiologically documented cases of anomalous bile duct drainage of a segment of the right lobe of the liver and/or the cystic duct. These anomalies may be suspected on preoperative, intraoperative, or postoperative cholangiograms by the lack of visualization of the bile ducts draining a focal portion of the right lobe of the liver ("naked segment"). They may also be diagnosed definitively by direct duct opacification. Radiologic diagnosis prior to cholecystectomy may prevent inadvertent ligation or injury to the aberrant duct.     

Congenital dilatation of the biliary tract; new classification and study with particular reference to anomalous arrangement of the pancreaticobiliary ducts

Yotsuyanagi's theory is often quoted in the discussion of the etiology of congenital dilatation of the biliary duct (CDBD), but there has been no established etiology as yet. With particular reference to the relationship between anomalous arrangement of the pancreaticobiliary ducts and CDBD, Babbit collected 19 cases of CDBD. The authors also observed the anomalous arrangement in 10 of 24 cases of CDBD (42 percent). Analysis of 570 CDBD cases collected in Japan disclosed that the anomalous arrangement was present in 183 of them (33 percent), dilation of the intraheptic bile ducts in 236 (42 percent), and narrowing and malformation of the bile duct in the hepatic hilum in 58 (10 percent). The authors have proposed a new classification, including these morphologic anomalies of the whole pancreaticobiliary ductal system. This classification provides useful indices in selecting the surgical procedures. The effect of the anomalous arrangement was pathophysiologically studied on dogs. The static internal pressure of the dog pancreatic duct was 14.6 + or - 5.5 cm H2O, and that of the dog bile duct, 8.9 + or - 3.4 cm H2O. Puppies were then operated on by shunting the pancreaticobiliary ducts. As the result, the biliary tract was devastated by pancreatic juice, giving rise to similar pathologic changes to those clinically observed.     

Aberrant hepatic duct connected with the main pancreatic duct by anomalous pancreato-biliary ductal union: Case report

An aberrant hepatic duct directly connected to the main pancreatic duct with anomalous arrangement of the pancreato-biliary ductal system is reported here, the first report of such a case, to our knowledge. A 53-year-old woman was admitted to our hospital because of cholecystolithiasis with abdominal pain in the right upper quadrant. Endoscopic retrograde cholangiopancreatography (ERCP) showed that an aberrant hepatic duct, which independently drained the right posterior segment of the liver, connected to the main pancreatic duct at a high insertion site distal to the sphincter area of the major papilla. The common bile duct (containing stones), on the other hand, united with the main pancreatic duct in a normal fashion. Cholecystectomy and bile duct lithotomy were performed. The aberrant hepatic duct was separated from the main pancreatic duct just above the junction, and was anastomosed side-by-side to the common hepatic duct. The embryologic development of this lesion is not clear, but is discussed in this report.